"We, the AIDS people. . .": how antiretroviral therapy enables Zimbabweans living with HIV/AIDS to cope with stigma

Expanding the food environment framework to include family dynamics: A systematic synthesis of qualitative evidence using HIV as a case study

Food environment changes in low- and middle-income countries are increasing diet-related noncommunicable diseases (NCDs). This paper synthesizes the qualitative evidence about how family dynamics shape food choices within the context of HIV (Prospero: CRD42021226283). Guided by structuration theory and food environment framework, we used best-fit framework analysis to develop the Family Dynamics Food Environment Framework (FDF) comprising three interacting dimensions (resources, characteristics, and action orientation). Findings show how the three food environment domains (personal, family, external) interact to affect food choices within families affected by HIV. Given the growing prevalence of noncommunicable and chronic diseases, the FDF can be applied beyond the context of HIV to guide effective and optimal nutritional policies for the whole family.

"I hope I die. That is what I hope for": Qualitative study of lived experiences of mental health of Indian women living with HIV experiencing intersectional stigma

Poor mental health due to stigma and discrimination has been well documented among women living with HIV. Although they often have other marginalized and stigmatized identities, little is known about their mental health as a result of experiencing multiple stigmas. Current narratives of mental health as a result of HIV-related stigma center on common mental health disorders such as anxiety and depression. However, biomedical diagnostic categories may not be as well known in all cultural and social contexts, and people may choose to express their distress in their own language. It is therefore important to listen to how women express their mental health concerns in their own language-their lived experiences-in order to best support them. To fill this research gap, semi-structured interviews were conducted in Kolkata, India, with 31 women living with HIV and 16 key informants. Data were coded and analyzed using thematic network analysis. The results showed that women suffered from poor mental health, which in turn affected their physical health. This happened through reduced adherence to medication, lowered CD4 counts, and the physical effects of stress, which could be perceived as prolonged. Participants described women's mental health concerns as worry, sadness, hopelessness, and fear, but biomedical diagnostic labels were rarely used. This allowed women to avoid additional stigmatization due to mental illness, which can attract some risk in this social context. As many women living with HIV experience poor mental health, they should be supported with a combination of psychosocial and psychological interventions. These include screening all women for mental illness and offering them mental health first aid. Those requiring additional support should be offered specialist psychotherapeutic and pharmacological care. This must be accompanied by stigma reduction interventions if they are to be successful in addressing the mental health needs of women living with HIV.

Antiretroviral therapy and aging as resources for managing and resisting HIV-related stigma in rural South Africa

The widespread roll-out of antiretroviral therapy (ART) in Africa has contributed to a large population of adults aging with HIV. However, little is known about how HIV-related stigma interacts with aging in the ART era. This study uses in-depth interviews with middle-aged and older South Africans living with HIV to explore stigma-related experiences and response strategies. Participants describe a persistence of stigma which requires the deployment of a range of common and age-based stigma management and resistance strategies. We find that participants minimize their exposure to stigma through selective disclosure of their HIV status; neutralize HIV-related stigma through comparisons to chronic illnesses common among older adults, and deflect stigma through asserting an ART-adherent identity and othering younger non-adherent adults. Overall, our study highlights the roles of ART and aging as resources for managing and resisting HIV-related stigma.

Exploring the beliefs, experiences and impacts of HIV-related self-stigma amongst adolescents and young adults living with HIV in Harare, Zimbabwe: A qualitative study

Background

HIV-related self-stigma is a significant barrier to HIV management. However, very little research has explored this phenomenon, particularly in sub-Saharan Africa. This study explored the beliefs, experiences, and impacts of HIV self-stigma amongst adolescents and young adults (AYALHIV) in Harare, Zimbabwe to inform future interventions. It aimed to capture the lived experience of self-stigmatization among AYALHIV and its impact on their social context using Corrigan et al (2009) self-stigma framework of ‘awareness’, ‘agreement’, and ‘application’.

Methods

Virtual semi-structured key informant interviews were conducted between June and July 2020 with adolescents and young adults (Female = 8; Male = 8) living with HIV (18–24 years) in Harare, Zimbabwe. We conducted the interviews with a purposive sample of AYALHIV enrolled in Africaid’s ‘Zvandiri’ program which provides HIV support services. Interviews were mainly conducted in English and with three in Shona, the main indigenous language. Audio-recorded qualitative data were transcribed, translated into English (where necessary) and deductively coded using Corrigan et al.’s self-stigma framework. The outbreak of SARS-CoV-2 coincided with the commencement of data collection activities, which impacted on both the sample size and a shift from in-person to virtual interviewing methods.

Results

Sixteen respondents (50% male) took part in the interviews. The mean age of respondents was 22 years. All respondents reported HIV-related self-stigma either occasionally or frequently. Three main themes of self-stigmatizing experiences emerged: disclosure, relationships, and isolation. These themes were then analyzed within the self-stigma development framework by Corrigan et al. (2009) known as ‘the three As’: awareness, agreement, and application of self-stigmatizing thoughts. Respondents’ experiences of self-stigma reportedly led to poor well-being and decreased mental and physical health. Gendered experiences and coping mechanisms of self-stigma were reported. Data suggested that context is key in the way that HIV is understood and how it then impacts the way people living with HIV (PLHIV) live with, and experience, HIV.

Conclusions

HIV-related negative self-perceptions were described by all respondents in this study, associated with self-stigmatizing beliefs that adversely affected respondents’ quality of life. Study findings supported Corrigan et al.’s framework on how to identify self-stigma and was a useful lens through which to understand HIV-related self-stigma among young people in Harare. Study findings highlight the need for interventions targeting PLHIV and AYALHIV to be context relevant if they are to build individual resilience, while working concurrently with socio-political and systemic approaches that challenge attitudes to HIV at the wider societal levels. Finally, the gendered experiences of self-stigma point to the intersecting layers of self-stigma that are likely to be felt by particularly marginalized populations living with HIV and should be further explored.

'You just prefer to die early!': how socioecological context impedes treatment for people living with HIV in Iran

INTRODUCTION

Despite the low prevalence of HIV and broad provision of antiretroviral therapy, the Middle East and North Africa (MENA) remains the only region where new HIV infections and AIDS-related deaths are not declining. There is a dearth of evidence from MENA on antiretroviral therapy engagement. In this qualitative study, we sought to identify the ways in which successful treatment is hindered in Iran, which is home to 24% of HIV infections in MENA.

METHODS

From August 2018 to January 2019, we used purposive sampling and conducted 12 individual interviews and 8 focus group discussions with 27 female and 31 male patients, in addition to 5 individual interviews with HIV care providers and 1 focus group discussion with 8 care providers. Social constructivism augmented with realist-informed thematic analysis was used to understand how the socioecological context triggers cognitive and affective mechanisms that disrupt antiretroviral therapy.

RESULTS

The use of Thematic Network Analysis resulted in the identification of three key cognitive and affective mechanisms that appear to shape treatment experience and are triggered via HIV's socioecological context and changing economic conditions in Iran: denial in response to societal negative perceptions of HIV; fear in response to societal lack of awareness regarding HIV and misinformation; and despair in response to HIV-related stigma and enacted discrimination, economic insecurity and social support.

CONCLUSIONS

To our knowledge, this is the first study within MENA to identify pathways through which successful treatment is hindered. It appears that lack of societal awareness regarding HIV is specific to low prevalence settings, such as MENA countries, where negative perceptions, stigma, discrimination and misinformation regarding HIV and its treatment produce denial, fear and despair, acting as mechanisms that disrupt antiretroviral therapy. The experience of despair, in response to changing economic conditions and social support, further impacts treatment experience.

In search of 'community': a critical review of community mental health services for women in African settings

Community is deemed a central resource for the improvement of health, across disciplines, contexts and conditions. However, what is meant by this term is rarely critically explored. In Global Mental Health, considerable efforts in recent years have been directed towards scaling up 'community' approaches, with variable success, creating the need to better understand approaches to its use. Our study contributes to this need, through a critical review of studies engaging with the term 'community' in relation to women's mental health services in African settings. Our review explored 30 peer-reviewed articles from the past 15 years, which were systematically evaluated for quality of evidence. Studies were then analysed using a blend of conventional and directed content analysis to unpack perspectives on the term's use in intervention and phenomenological studies. We identified four broad categories of community: (1) place (shared geographical location or institutional affiliation), (2) practice (belongingness to a shared activity or profession), (3) symbols (meanings and experiences associated with shared community life) and (4) identity (diagnostic identity around a mental health condition). Analysis identified community of place as the most common primary focus of interest across the sample, with 80% of papers referencing this dimension. We noted that in studies where communities of practice were the focus, this was in relation to leveraging local knowledge to inform or support service delivery of intervention programmes, often designed by outsiders. Implications for future policy and mental health services research are discussed.

Pathways for reduction of HIV-related stigma: a model derived from longitudinal qualitative research in Kenya and Uganda

INTRODUCTION

The rollout of antiretroviral therapy (ART) has been associated with reductions in HIV-related stigma, but pathways through which this reduction occurs are poorly understood. In the newer context of universal test and treat (UTT) interventions, where rapid diffusion of ART uptake takes place, there is an opportunity to understand the processes through which HIV-related stigma can decline, and how UTT strategies may precipitate more rapid and widespread changes in stigma. This qualitative study sought to evaluate how a UTT intervention influenced changes in beliefs, attitudes and behaviours related to HIV.

METHODS

Longitudinal qualitative in-depth semi-structured interview data were collected within a community-cluster randomized UTT trial, the Sustainable East Africa Research in Community Health (SEARCH) study, annually over three rounds (2014 to 2016) from two cohorts of adults (n = 32 community leaders, and n = 112 community members) in eight rural communities in Uganda and Kenya. Data were inductively analysed to develop new theory for understanding the pathways of stigma decline.

RESULTS

We present an emergent theoretical model of pathways through which HIV-related stigma may decline: internalized stigma may be reduced by two processes accelerated through the uptake and successful usage of ART: first, a reduced fear of dying and increased optimism for prolonged and healthy years of life; second, a restoration of perceived social value and fulfilment of subjective role expectations via restored physical strength and productivity. Anticipated stigma may be reduced in response to widespread engagement in HIV testing, leading to an increasing number of HIV status disclosures in a community, "normalizing" disclosure and reducing fears. Improvements in the perceived quality of HIV care lead to people living with HIV (PLHIV) seeking care in nearby facilities, seeing other known community members living with HIV, reducing isolation and facilitating opportunities for social support and "solidarity." Finally, enacted stigma may be reduced in response to the community viewing the healthy bodies of PLHIV successfully engaged in treatment, which lessens the fears that trigger enacted stigma; it becomes no longer socially normative to stigmatize PLHIV. This process may be reinforced through public health messaging and anti-discrimination laws.

CONCLUSIONS

Declines in HIV-related stigma appear to underway and explained by social processes accelerated by UTT efforts. Widespread implementation of UTT shows promise for reducing multiple dimensions of stigma, which is critical for improving health outcomes among PLHIV.

HIV-related stigma trends in the general population of India during an era of antiretroviral treatment expansion, 2005-16

BACKGROUND

In India, which has the world's third-largest HIV epidemic, the extent to which levels of HIV-related stigma have changed during an era of ART scale-up is unknown.

METHODS

We analyzed data from the 2005-06 and 2015-16 National Family Health Surveys (NFHS) to estimate trends in two stigma domains among people in the general population: desires for social distance from people living with HIV (ie, unwillingness to interact) and fear of serostatus disclosure in the case of a hypothetical HIV infection. We fitted multivariable linear probability models to the data with year of NFHS as the explanatory variable and alternately specifying fear of disclosure or desires for social distance as the dependent variable. Analyses were stratified by sex, state, and high vs low HIV prevalence states.

RESULTS

We included data on 172 795 women and 159 194 men. Desires for social distance declined in 2015-16 compared with 2005-06 (38% in 2015-16 vs 43% in 2005-06; adjusted b = -0.046; 95% confidence interval (CI = -0.049 to -0.043; P < 0.001) but fear of serostatus disclosure increased (31% in 2005-06 vs 37% in 2015-16; adjusted b = 0.058; 95% CI = 0.055-0.062; P < 0.001). Declines in social distancing were more pronounced among men and in high HIV prevalence states. Increased fear of serostatus disclosure was greater among women and in high HIV prevalence states. There was significant variability in trends disaggregated by state.

CONCLUSIONS

During the first decade of ART scale-up in India, fear of HIV serostatus disclosure in the general population increased despite a decline in desires for social distance.

The push of stigma: a qualitative study on the experiences and consequences of sexuality stigma among same-sex attracted men in Harare, Zimbabwe

This paper describes experiences of sexuality stigma among same-sex attracted men in Zimbabwe and analyses the consequences of such experiences for healthcare seeking. It draws on qualitative research carried out in Harare in 2017, which included in-depth interviews with sixteen gay and bisexual men, and key informant interviews with three representatives of organisations that work with gay men. There were numerous stories about sexuality stigma in the study participants´ social environments, including at home, in local communities and in healthcare facilities. We first offer a description of these and then go on to trace the implications of stigma on the relations between men who have sex with men on the one hand and the healthcare sector on the other. We conceive of stigma as a pushing force that exerts pressure on and in these relations, and identify five types of consequences of this. Stigma works to (1) produce geographical shifts in healthcare, (2) promote private over public care, (3) compartmentalise healthcare (with dedicated providers for queer persons), (4) deprofessionalise care, and (5) block access to appropriate healthcare altogether for some same-sex attracted men. Most of these consequences have negative implications for preventive or treatment-focused HIV programming.

Temporal and cross-national comparisons of young Africans' HIV-related narratives from five countries, 1997-2014

Little is known about how young Africans have made sense of the dramatic ways in which the HIV epidemic has evolved, and how that sense-making varies across countries with different epidemiological and sociocultural profiles. Symbolic representations of HIV and people living with HIV influence prevention, stigma, treatment-seeking, and illness experience. We compared social representations of HIV among young people from Senegal, Burkina Faso, Nigeria (South-East), Kenya, and Swaziland between 1997 and 2014. From a pool of 32,759 HIV-themed creative narratives contributed by 10-24 year-olds to scriptwriting competitions at eight time points (1997, 2000, 2002, 2005, 2008, 2011, 2013, and 2014), we randomly sampled 1937 narratives, stratified by author's sex, age, and rural/urban residence. We quantified components of each narrative and calculated descriptive statistics and adjusted odds ratios, controlling for year, country, and author demographics. From 2005 onwards, representations of death, treatment access, and hopefulness improved significantly. Representations of death reached their lowest point in 2013, while biomedical treatment and hope peaked in 2011 and 2008, respectively, then declined. Narratives increasingly focused on female protagonists. Nigerian texts had significantly higher odds of death and blame, and lower odds of hope. A focus on life post-infection and representations of support for characters living with HIV increased with country HIV prevalence. Narratives by older authors were less blaming and more hopeful, supportive, and prevention-focused. While aggregate social representations in the narratives from 2005 to 2008-11 reflect increased optimism fostered by access to antiretroviral therapy (ART), positive developments are not sustained at this level. Stigmatizing representations persist, particularly in Nigeria. The hope-promoting and stigma-reducing influence of the advent of ART access may have partially run its course by 2011/2013. However, significant temporal and cross-national differences point to opportunities to reframe HIV in more constructive ways and contribute to improved education, communication, and stigma-reduction efforts.

Perceptions of HIV-related trauma in people living with HIV in Zimbabwe's Friendship Bench Program: A qualitative analysis of counselors' and clients' experiences

This study investigated the experience of lay health workers (LHWs) delivering problem-solving therapy (PST) for common mental disorders (CMD) as well as clients' views of the PST program referred to as the Friendship Bench (FB). Semi-structured interviews were conducted with LHWs (n = 5) and clients living with HIV (PLWH) (n = 10). Data were analyzed using thematic content analysis. LHWs described a severe form of CMD amongst PLWH with a history of trauma, naming it kufungisisa kwe njodzi (excessive thinking due to trauma), a local cultural equivalent of PTSD. The term kufungisisa (thinking too much) has been used as the local equivalent for CMD. Trauma or njodzi was seen both as a circumscribed event and as linked to ongoing pervasive experiences such as living with HIV, stigma, and poverty. Although LHWs recognized symptoms of PTSD such as intrusion, avoidance, and hyper-arousal, they did not know how to address these specifically and chose to address them as a severe form of kufungisisa. There is a need to integrate aspects of PTSD management within care packages for CMD delivered by LHWs.

Community beliefs, HIV stigma, and depression among adolescents living with HIV in rural Uganda

The availability of and increased access to antiretroviral therapy (ART) has significantly reduced the morbidity and mortality associated with HIV. As a result, perinatally infected youth are increasingly able to reach adolescence. There is limited information about the psychosocial challenges facing adolescents living with HIV (ALWH) in rural settings of sub-Saharan Africa. We sought to understand psychosocial challenges facing ALWH in rural Uganda and their effects on mental health and HIV treatment outcomes. We conducted 5 focus group discussions and 40 one-on-one in-depth interviews in Mbarara, Uganda with adolescents (aged 13-17 years) and adult women caregivers. All interviews were audio-recorded, transcribed directly into English, and coded using thematic analysis to identify themes related to psychosocial adversities and mental health. Adversities faced by adolescents included negative community perceptions (perceived aggression, presumed early mortality), HIV stigma (enacted and internalized), vulnerability factors (loss of parents, poverty), and health challenges (depression, ART non-adherence). In the conceptual model that emerged from the findings, negative community perceptions (about perceived aggression or presumed early mortality) predisposed ALWH to experience enactments and internalization of stigma that led to depression and ART non-adherence. The data also identified several protective factors, including counselling, family and religious support, and timely serostatus disclosure. Interventions to correct community misperceptions about HIV can potentially reduce stigma and thereby improve physical and mental health outcomes of ALWH.

Depressive Symptoms Before and After Antiretroviral Therapy Initiation Among Older-Aged Individuals in Rural Uganda

This study aims to characterize associations between depression symptom severity and HIV infection, both prior to and in years after ART initiation, among older adults. The Ugandan Non-Communicable Diseases & Aging Cohort Study (UGANDAC) is a study of 154 PLWH on ART and 142 community-based, HIV-negative controls. The Hopkins Checklist (HSCL), a 15-item depression scale, was used to screen for depression. We estimate differences in depressive symptoms by HIV and ART status and use multivariable log binomial regression to quantify differences in probable depression between PLWH on ART. HIV-infected and HIV-uninfected participants had a similar age (mean 52.0 vs. 51.9, p = 0.854) and sex distribution (47.4 vs. 47.9% female, p = 0.934). PLWH on ART had lower depression symptom severity than HIV-uninfected controls (mean score: 1.50 vs. 1.60, p = 0.006) and a lower prevalence of probable depression (21.4 vs. 33.8%, p = 0.017). Among 102 PLWH with pre-ART depression screening scores available, their mean depression symptom severity was similar to HIV-uninfected participants (mean 1.56 vs. 1.60, p = 0.512). In adjusted models, PLWH on ART had a lower prevalence of probable depression than HIV-negative controls [adjusted prevalence ratio: 0.68 (95% CI 0.47-0.99)]. In an observational cohort of PLWH over 40 on long-term ART and matched, community-based HIV-uninfected controls in rural Uganda, we found a lower prevalence of self-reported depression among aging PLWH on ART.

"I don't want them to know": how stigma creates dilemmas for engagement with Treat-all HIV care for people living with HIV in Eswatini

"Treat-all" programmes aim to improve clinical outcomes and to reduce HIV transmission through regular HIV testing and immediate offer of antiretroviral therapy (ART) for those diagnosed HIV-positive, irrespective of immunological status and symptoms of disease. Global narratives on the benefits of Treat-all anticipate reduced HIV-related stigma and increased "normalisation" of HIV with Treat-all implementation, whereby HIV is remoulded as a manageable, chronic condition where stigmatising symptoms can be concealed. Drawing on Goffman's stigma work, we aimed to investigate how stigma may influence the engagement of clinically asymptomatic people living with HIV (PLHIV) with Treat-all HIV care in Shiselweni, Eswatini (formerly Swaziland). This longitudinal research comprised 106 interviews conducted from August 2016 to September 2017, including repeated interviews with 30 PLHIV, and one-off interviews with 20 healthcare workers. Data were analysed thematically using NVivo 11, drawing upon principles of grounded theory to generate findings inductively from participants' accounts. Stigma was pervasive within the narratives of PLHIV, framing their engagement with treatment and care. Many asymptomatic PLHIV were motivated to initiate ART in order to maintain a "discreditable" status, by preventing the development of visible and exposing symptoms. However, engagement with treatment and care services could itself be exposing. PLHIV described the ways in which these "invisibilising" benefits and exposing risks of ART were continually assessed and navigated over time. Where the risk of exposure was deemed too great, this could lead to intermittent treatment-taking, and disengagement from care. Addressing HIV related stigma is crucial to the success of Treat-all, and should thus be a core component of HIV responses.

The rebellious man: Next-of-kin accounts of the death of a male relative on antiretroviral therapy in sub-Saharan Africa

The HIV response is hampered by many obstacles to progression along the HIV care cascade, with men, in particular, experiencing different forms of disruption. One group of men, whose stories remain untold, are those who have succumbed to HIV-related illness. In this paper, we explore how next-of-kin account for the death of a male relative. We conducted 26 qualitative after-death interviews with family members of male PLHIV who had recently died from HIV in health and demographic surveillance sites in Malawi, Tanzania, Kenya, Uganda, Zimbabwe and South Africa. The next-of-kin expressed frustration about the defiance of their male relative to disclose his HIV status and ask for support, and attributed this to shame, fear and a lack of self-acceptance of HIV diagnosis. Next-of-kin painted a picture of their male relative as rebellious. Some claimed that their deceased relative deliberately ignored instructions received by the health worker. Others described their male relatives as unable to maintain caring relationships that would avail day-to-day treatment partners, and give purpose to their lives. Through these accounts, next-of-kin vocalised the perceived rebellious behaviour of these men, and in the process of doing so neutralised their responsibility for the premature death of their relative.

Trajectories of HIV-related internalized stigma and disclosure concerns among ART initiators and non-initiators in South Africa

Background

HIV-related stigma among people living with HIV (PLHIV) is associated with worse health outcomes. We used longitudinal data from a multi-site cohort in South Africa to assess changes over time in stigma after HIV diagnosis and determine whether antiretroviral therapy (ART) initiation is associated with stigma reduction.

Methods

We administered the Internalized AIDS-Related Stigma Scale (IARSS, a six-item dichotomous scale questionnaire) at baseline, three months, and six months to newly diagnosed ART-eligible participants between 2014-2015. A confirmatory factor analysis indicated that the IARSS contained a four-item internalized stigma factor (α=0.80) and a two-item disclosure concerns factor (α=0.75). We fitted multiple logistic regression models specifying internalized stigma/disclosure concerns at six months as the outcome and ART initiation as the predictor of interest.

Results

Of the 500 participants (187 men and 313 women) enrolled, 308 (62%) initiated ART. Internalized stigma declined among people entering care (mean score, 1.0 to 0.7, p<0.01); however, disclosure concerns remained unchanged (percentage endorsing either disclosure concern item, 78% to 77%, p=0.23). These findings were similar between ART initiators and non-initiators. We estimated a statistically significant positive association between ART initiation and disclosure concerns at six months (OR=1.88; 95% CI, 1.20-2.94) but not between ART initiation and internalized stigma at six months (OR=1.15; 95% CI, 0.75-1.78).

Conclusions

Among ART-eligible South African PLHIV entering into HIV care, internalized stigma modestly declined over time but disclosure concerns persisted. PLHIV who initiated ART were more likely to have persistent disclosure concerns over time as compared with those who did not start ART.

HIV stigma experiences and stigmatisation before and after a HIV stigma-reduction community "hub" intervention

This study sought to explore, describe and determine whether an HIV stigma-reduction community "hub" intervention would change the HIV stigma experiences of people living with HIV (PLWH) and the stigmatisation by the community in an urban area in South Africa. A convergent parallel mixed-method design with a single case pre-test post-test design and an interpretive description approach was utilised. The sample for this study included 62 PLWH recruited through accessibility sampling and 570 community members recruited through random voluntary sampling. A sub-sample of both groups, selected using purposive voluntary sampling, was utilised for the in-depth interviews about stigma experiences of PLWH, and for perceptions and attitudes of the community toward PLWH. Both quantitative and qualitative data showed that stigma is present. Although no statistically significant changes were found, small practically significant changes were demonstrated in the experiences of PLWH and in the perceptions and attitudes of the community. The extent of changes was much more obvious in the responses of the PLWH and the community during their post-intervention qualitative interviews than the changes found with the quantitative measures. This study thus concludes that the HIV stigma-reduction community hub intervention was successful in initiating the onset of changes in a community through the PLWH and people living close to PLWH (PLC) as community mobilisers active in the community hub to mobilise their own communities towards HIV stigma reduction through social change.

Internalized HIV stigma, bullying, major depressive disorder, and high-risk suicidality among HIV-positive adolescents in rural Uganda

BACKGROUND

Studies conducted in sub-Saharan Africa suggest a high prevalence of depression and suicidality among adolescents living with HIV (ALWH). This is an important public health issue because depression is known to compromise HIV treatment adherence. However, the drivers of depression and suicidality in this population are unclear. We conducted a cross-sectional study to estimate the associations between internalized stigma, bullying, major depressive disorder, and suicidality.

METHODS

We conducted a cross-sectional survey between November 2016 and March 2017, enrolling a consecutive sample of 224 ALWH aged 13-17 years. We collected information on demographic characteristics, internalized HIV-related stigma (using the six-item Internalized AIDS-Related Stigma Scale), bullying victimization (using the nine-item Social and Health Assessment Peer Victimization Scale), major depressive disorder [using the Mini International Neuropsychiatric Interview for Children and Adolescents (MINI-KID)], and suicidality (also using the MINI-KID). We fitted multivariable logistic regression models to estimate the associations between stigma, bullying, major depressive disorder, and suicidality.

RESULTS

Thirty-seven participants (16%) had major depressive disorder, 30 (13%) had suicidality, and nine (4%) had high-risk suicidality. Ninety-one participants (41%) had high levels of internalized stigma, while 97 (43%) reported two or more bullying events in the past year. In multivariable logistic regression models, major depressive disorder had a statistically significant association with bullying (AOR = 1.09; 95% CI 1.00-1.20; p = 0.04); while suicidality (low, moderate, high risk) had statistically significant associations with both bullying (AOR = 1.09; 95% CI 1.01-1.17; p = 0.02) and stigma (AOR = 1.30; 95% CI 1.03-1.30; p = 0.02).

CONCLUSIONS

Among ALWH in rural Uganda, stigma and bullying are strongly associated with major depressive disorder and suicidality. There is a need to incorporate psychological interventions in the mainstream HIV care to address these challenges for optimal management of HIV among ALWH.

Changing forms of HIV-related stigma along the HIV care and treatment continuum in sub-Saharan Africa: a temporal analysis

OBJECTIVES

Stigma remains pervasive for people living with HIV (PLHIV) in sub-Saharan Africa, undermining care engagement. Using everyday, biographical and epochal temporalities, we explored the manifestation of stigma at different stages of the HIV care continuum in seven health and demographic surveillance sites in Eastern and Southern Africa.

METHODS

Between 2015 and 2016, we conducted qualitative in-depth interviews with 264 PLHIV, 54 health providers and 48 family members of people who had died from HIV. Topic guides explored experiences of HIV testing, care and treatment services. Data were analysed thematically, aided by NVivo 10.

RESULTS

In everyday time across these communities, stigma was evident in the presence of gossiping and the relative absence of supportive interpersonal discourse, which fuelled judicious disclosure. This was especially disruptive at testing, counselling and early antiretroviral therapy adherence stages of care. Biographical time framed everyday stigma events, highlighting the dilemma of disclosure in relation to sexual relationship norms, as well as the interfacing of age and healthcare continuum points. Epochal patriarchal relations gave a structural context to everyday and biographical stigma dynamics. Historical shifts to social acceptance of PLHIV within these communities, while positive, were complicated by stigma in everyday life and in respect of biographical goals like having a family. Moreover, low community-level resistance to HIV-related stigma jeopardised stigma reduction strategies.

CONCLUSIONS

Despite improvements to HIV care services, stigma remains pervasive across the HIV care continuum in these sites. Context-specific interventions are needed to address stigma and discrimination of PLHIV within the community and in health services, and greater reflection is required to ensure policies aiming to expand HIV treatment do not exacerbate stigma and result in negative HIV outcomes.

Identifying Strategies to Cope with HIV-Related Stigma in a Group of Women Living with HIV/AIDS in the Dominican Republic: A Qualitative Study

Internalized HIV-related stigma negatively impacts the mental and physical health of women living with HIV/AIDS (WLWHA). Yet, some women can successfully confront stigma. The present work uses qualitative methods to investigate the successful stigma coping strategies displayed by 19 WLWHA who reported the least internalized stigma possible on the Internalized AIDS-Related Stigma Scale out of a larger pool of 233 WLWHA in San Felipe de Puerto Plata, Dominican Republic. Such strategies included, HIV disclosure control; preemptive disclosure of HIV-status; educating oneself/others about HIV; viewing HIV as a manageable condition; and looking to family, friends and partners for support. Our findings add to current knowledge about how WLWHA successfully manage internalized stigma, particularly in the context of the Dominican Republic. Clinicians should work closely with WLWHA to counsel them about the stigma coping strategies that best fit their life context.

HIV stigma trends in the general population during antiretroviral treatment expansion: analysis of 31 countries in sub-Saharan Africa, 2003-2013

BACKGROUND

HIV-related stigma is associated with increased risk-taking behavior, reduced uptake of HIV testing, and decreased adherence to antiretroviral therapy (ART). Although ART scale-up may reduce HIV-related stigma, the extent to which levels of stigma in the general population have changed during the era of ART scale-up in sub-Saharan Africa is unknown.

METHODS

Social distance and anticipated stigma were operationalized using standard HIV-related stigma questions contained in the Demographic and Health Surveys and AIDS Indicator Surveys of 31 African countries between 2003 and 2013. We fitted multivariable linear regression models with cluster-correlated robust standard errors and country fixed effects, specifying social distance or anticipated stigma as the dependent variable and year as the primary explanatory variable of interest.

RESULTS

We estimated a statistically significant negative association between year and desires for social distance (b = -0.020; P < 0.001; 95% confidence interval: -0.026 to -0.015) but a statistically significant positive association between year and anticipated stigma (b = 0.023; P < 0.001; 95% confidence interval: 0.018 to 0.027). In analyses stratified by HIV prevalence above or below the sample median, declines in social distancing over time were more pronounced among countries with a higher HIV prevalence.

CONCLUSIONS

Concomitant with ART scale-up in sub-Saharan Africa, anticipated stigma in the general population increased despite a decrease in social distancing toward people living with HIV. Although ART scale-up may help reduce social distancing toward people living with HIV, particularly in high-prevalence countries, other interventions targeting symbolic or instrumental concerns about HIV may be needed.

Negotiations of Blame and Care among HIV-positive Mothers and Daughters in South Africa's Eastern Cape

Research delineates two epidemiological categories among HIV-positive adolescents: those who contract the virus sexually and those who inherit it as infants. In this article, we are interested in how tacit inferences about adolescents' mode of infection contribute to their experiences of HIV-related blame, and their ability to achieve care, in their intimate, everyday settings. The analysis arises from ethnographic research with 23 HIV-positive adolescents living in South Africa's Eastern Cape. From these, we draw particularly on the narratives of four HIV-positive teenage girls and their HIV-positive mothers. The article explores the social stakes entailed in ascriptions of adolescents' mode of infection, particularly in terms of how blame was allocated between mothers and daughters. It further considers how these families have sought to negotiate repudiation and thereby sustain intergenerational care. The article furthers limited research on the life projects and dilemmas of this HIV-positive adolescent cohort.

Psychosocial well-being of people living with HIV and the community before and after a HIV stigma-reduction community "hub" network intervention

The purpose of the research was to determine whether an HIV stigma-reduction community "hub" network intervention in a South African urban area would bring about a difference in the psychosocial well-being of people living with HIV (PLWH), as well as their community (living in the same municipal ward). A single case pre-test post-test design was implemented. The sample for this study included 62 PLWH who were selected through accessibility sampling and 570 community members who were selected through random voluntary sampling. Participants completed the Patient Health Questionnaire (PHQ-9) and the Mental Health Continuum-Short Form (MHC-SF) before and after the intervention. A dependent t-test as well as Cohen's d-values were used to calculate the differences between the pre- and post-test results for depression and well-being. Levels of languishing, moderate mental health and flourishing before and after the intervention were determined. Although the focus of the HIV stigma-reduction community "hub" intervention that was followed in this study was on the involvement of PLWH and people living close to them (PLC) to share their knowledge as community mobilisers and to mobilise and empower their own community to reduce HIV stigma, it can be concluded that a secondary gain was the effect it had on both depression and mental health of the PLWH as well as the community. Of interest is how these effects differed for PLWH and the community. It is thus recommended that future interventions should give special attention to aspects of depression and well-being.

A Livelihood Intervention to Reduce the Stigma of HIV in Rural Kenya: Longitudinal Qualitative Study

The scale-up of effective treatment has partially reduced the stigma attached to HIV, but HIV still remains highly stigmatized throughout sub-Saharan Africa. Most studies of anti-HIV stigma interventions have employed psycho-educational strategies such as information provision, counseling, and testimonials, but these have had varying degrees of success. Theory suggests that livelihood interventions could potentially reduce stigma by weakening the instrumental and symbolic associations between HIV and premature morbidity, economic incapacity, and death, but this hypothesis has not been directly examined. We conducted a longitudinal qualitative study among 54 persons with HIV participating in a 12-month randomized controlled trial of a livelihood intervention in rural Kenya. Our study design permitted assessment of changes over time in the perspectives of treatment-arm participants (N = 45), as well as an understanding of the experiences of control arm participants (N = 9, interviewed only at follow-up). Initially, participants felt ashamed of their seropositivity and were socially isolated (internalized stigma). They also described how others in the community discriminated against them, labeled them as being "already dead," and deemed them useless and unworthy of social investment (perceived and enacted stigma). At follow-up, participants in the treatment arm described less stigma and voiced positive changes in confidence and self-esteem. Concurrently, they observed that other community members perceived them as active, economically productive, and contributing citizens. None of these changes were noted by participants in the control arm, who described ongoing and continued stigma. In summary, our findings suggest a theory of stigma reduction: livelihood interventions may reduce internalized stigma among persons with HIV and also, by targeting core drivers of negative attitudes toward persons with HIV, positively change attitudes toward persons with HIV held by others. Further research is needed to formally test these hypotheses, assess the extent to which these changes endure over the long term, and determine whether this class of interventions can be implemented at scale.

Overlapping HIV and sex-work stigma among female sex workers recruited to 14 respondent-driven sampling surveys across Zimbabwe, 2013

HIV stigma can inhibit uptake of HIV testing and antiretroviral therapy as well as negatively affect mental health. Efforts to reduce discrimination against people living with HIV (LWH) have contributed to greater acceptance of the infection. Female sex workers (FSW) LWH may experience overlapping stigma due to both their work and HIV status, although this is poorly understood. We examined HIV and sex-work stigma experienced by FSW LWH in Zimbabwe. Using the SAPPH-IRe cluster-randomised trial baseline survey, we analysed the data from 1039 FSW self-reporting HIV. The women were recruited in 14 sites using respondent-driven sampling. We asked five questions to assess internalised and experienced stigma related to working as a sex worker, and the same questions were asked in reference to HIV. Among all FSW, 91% reported some form of sex-work stigma. This was not associated with sociodemographic or sex-work characteristics. Rates of sex-work stigma were higher than those of HIV-related stigma. For example, 38% reported being "talked badly about" for LWH compared with 77% for their involvement in sex work. Those who reported any sex-work stigma also reported experiencing more HIV stigma compared to those who did not report sex-work stigma, suggesting a layering effect. FSW in Zimbabwe experience stigma for their role as "immoral" women and this appears more prevalent than HIV stigma. As HIV stigma attenuates, other forms of social stigma associated with the disease may persist and continue to pose barriers to effective care.

A livelihood intervention to improve economic and psychosocial well-being in rural Uganda: Longitudinal pilot study

HIV and poverty are inextricably intertwined in sub-Saharan Africa. Economic and livelihood intervention strategies have been suggested to help mitigate the adverse economic effects of HIV, but few intervention studies have focused specifically on HIV-positive persons. We conducted three pilot studies to assess a livelihood intervention consisting of an initial orientation and loan package of chickens and associated implements to create poultry microenterprises. We enrolled 15 HIV-positive and 22 HIV-negative participants and followed them for up to 18 months. Over the course of follow-up, participants achieved high chicken survival and loan repayment rates. Median monthly income increased, and severe food insecurity declined, although these changes were not statistically significant (P-values ranged from 0.11 to 0.68). In-depth interviews with a purposive sample of three HIV-positive participants identified a constellation of economic and psychosocial benefits, including improved social integration and reduced stigma.

Health-related quality of life of patients on antiretroviral treatment in Botswana: A cross-sectional study

OBJECTIVE

Antiretroviral therapy (ART) affords longevity to patients infected with the human immune deficiency virus (HIV). Since little is known about the health-related quality of life (HRQoL) of persons who have been on ART for at least five years, the present study investigated the HRQoL of these patients in Botswana.

METHOD

Medical records, structured interviews, and the World Health Organization Quality of Life-BREF (WHOQoL-HIV-BREF) instrument were employed to obtain information from 456 respondents.

RESULTS

Univariate and multivariate regression analyses showed that respondents' highest scores were in the "physical" domain (mean = 15.8, SD = 3.5), while the lowest scores were in the "environment" domain (mean = 12.9, SD = 2.5). Thus, the physical domain had the greatest impact on patients' overall HRQoL. Self-education about HIV-related issues was significantly correlated with all domains of HRQoL scores: physical (ρ = -2.32, CI 95% = -3.02, -1.61); psychological (ρ = -2.26, CI 95% = -2.87, -1.65); independence (ρ = -1.81, CI 95% = -2.54, -1.06); social relationships (ρ = -1.40, CI 95% = -2.13, -0.67); environment (ρ = -1.58, CI 95% = -2.13, -1.04); and spirituality (ρ = -1.70, CI 95% = -82.27, -1.13).

SIGNIFICANCE OF RESULTS

HRQoL assessments can identify and address patients' needs, and it is important that guidelines be developed that will yield improved care to ART patients in Botswana.

Reducing the overall HIV-burden in South Africa: is 'reviving ABC' an appropriate fit for a complex, adaptive epidemiological HIV landscape?

This article questions the recommendations to 'revive ABC (abstain, be faithful, condomise)' as a mechanism to 'educate' people in South Africa about HIV prevention as the South African National HIV Prevalence, Incidence and Behaviour Survey, 2012, suggests. We argue that ABC was designed as a response to a particular context which has now radically changed. In South Africa the contemporary context reflects the mass roll-out of antiretroviral treatment; significant bio-medical knowledge gains; a generalised population affected by HIV that has made sense of and embodied those diverse experiences; and a government committed to confronting the epidemic. We suggest that the situation can now be plausibly conceptualised as a complex, adaptive epidemiological landscape that could benefit from an expansion of the existing, 'descriptive' prevention paradigm towards strategies that focus on the dynamics of transmission. We argue for this shift by proposing a theoretical framework based on complexity theory and pattern management. We interrogate one educational prevention heuristic that emphasises the importance of risk-reduction through the lens of transmission, called A-3B-4C-T. We argue that this type of approach provides expansive opportunities for people to engage with the epidemic in contextualised, innovative ways that supersede the opportunities afforded by ABC. We then suggest that framing the prevention imperative through the lens of 'dynamic prevention' at scale opens more immediate opportunities, as well as developing a future-oriented mind-set, than the 'descriptive prevention' parameters can facilitate. The parameters of the 'descriptive prevention' paradigm, that maintain - and partially reinforce - the presence of ABC, do not have the flexibility required to develop the armamentarium of tools required to contribute to the management of a complex epidemiological landscape. Uncritically adhering to both the 'descriptive paradigm', and ABC, represents an historically dislocated form of prevention - with restrictive options for reducing the overall burden of HIV-related challenges in South Africa.

Re-imagining decision making: addressing a discrete social driver of HIV/AIDS through the lens of complexity science

This article argues that decision making is a discrete social driver that can be associated with the HIV/AIDS epidemic in the Limpopo province in South Africa. The authors argue that complexity science can inform future research and interventions by presenting two decision making frameworks arising out of complexity science that have the potential to enable young people to better negotiate decision-making contexts whilst simultaneously opening spaces of dialogue that can mitigate the impact of HIV-risk in specific, punctuated contexts. The methodological design was prompted by findings from youth-oriented community engagement projects that include Communication Conversations and Sex & Relationships Education. The proposed methods have the potential to exploit the phenomenon of leadership emergence as a product of decision making at critical moments. This has the potential to promote the growth of home-grown leadership skill sets that make sense to young people and to enable them better manage their own health, thus reducing risk and vulnerability to HIV infection and sexual violence.

Antiretroviral therapy and changing patterns of HIV stigmatisation in Entebbe, Uganda

Antiretroviral therapy (ART) has the potential to change processes of HIV stigmatisation. In this article, changing processes of stigmatisation among a group of people living with HIV (PLWH) on ART in Wakiso District, Uganda, are analysed using qualitative data from a study of PLWH's self-management of HIV on ART. There were 38 respondents (20 women, 18 men) who had been taking ART for at least 1 year. They were purposefully selected from government and non-government ART providers. Two in-depth interviews were held with each participant. Processes of reduced self-stigmatisation were clearly evident, caused by the recovery of their physical appearance and support from health workers. However most participants continued to conceal their status because they anticipated stigma; for example, they feared gossip, rejection and their status being used against them. Anticipated stigma was gendered: women expressed greater fear of enacted forms of stigma such as rejection by their partner; in contrast men's fears focused on gossip, loss of dignity and self-stigmatisation. The evidence indicates that ART has not reduced underlying structural drivers of stigmatisation, notably gender identities and inequalities, and that interventions are still required to mitigate and tackle stigmatisation, such as counselling, peer-led education and support groups that can help PLWH reconstruct alternative and more positive identities. A video abstract of this article can be found at: https://youtu.be/WtIaZJQ3Y_8.

A good patient? How notions of 'a good patient' affect patient-nurse relationships and ART adherence in Zimbabwe

BACKGROUND

While patient-provider interactions are commonly understood as mutually constructed relationships, the role of patient behaviour, participation in interactions, and characteristics, particularly ideals surrounding notions of 'good' and 'bad' patients, are under-examined. This article examines social representations of 'a good patient' and how these representations affect patient-healthcare provider relationships and antiretroviral treatment (ART) for people living with HIV.

METHODS

Using thematic network analysis, we examined interview and focus group transcripts involving 25 healthcare staff, 48 ART users, and 31 carers of HIV positive children, as well as field notes from over 100 h of ethnographic observation at health centres in rural Zimbabwe.

RESULTS

Characteristics of a good patient include obedience, patience, politeness, listening, enthusiasm for treatment, intelligence, physical cleanliness, honesty, gratitude and lifestyle adaptations (taking pills correctly and coming to the clinic when told). As healthcare workers may decide to punish patients who do not live up the 'good patient persona', many patients seek to perform within the confines of the 'good patient persona' to access good care and ensure continued access to ART.

DISCUSSION

The notion of a 'good ART patient' can have positive effects on patient health outcomes. It is one of the only arenas of the clinic experience that ART patients can influence in their favour. However, for people not conforming to the norms of the 'good patient persona', the productive and health-enabling patient-nurse relationship may break down and be detrimental to the patient.

CONCLUSION

We conclude that policy makers need to take heed of the social representations that govern patient-nurse relationships and their role in facilitating or undermining ART adherence.

Contemporary issues on the epidemiology and antiretroviral adherence of HIV-infected adolescents in sub-Saharan Africa: a narrative review

Introduction

Adolescents are a unique and sometimes neglected group in the planning of healthcare services. This is the case in many parts of sub-Saharan Africa, where more than eight out of ten of the world's HIV-infected adolescents live. Although the last decade has seen a reduction in AIDS-related mortality worldwide, largely due to improved access to effective antiretroviral therapy (ART), AIDS remains a significant contributor to adolescent mortality in sub-Saharan Africa. Although inadequate access to ART in parts of the subcontinent may be implicated, research among youth with HIV elsewhere in the world suggests that suboptimal adherence to ART may play a significant role. In this article, we summarize the epidemiology of HIV among sub-Saharan African adolescents and review their adherence to ART, emphasizing the unique challenges and factors associated with adherence behaviour.

Methods

We conducted a comprehensive search of online databases for articles, relevant abstracts, and conference reports from meetings held between 2010 and 2014. Our search terms included “adherence,” “compliance,” “antiretroviral use” and “antiretroviral adherence,” in combination with “adolescents,” “youth,” “HIV,” “Africa,” “interventions” and the MeSH term “Africa South of the Sahara.” Of 19,537 articles and abstracts identified, 215 met inclusion criteria, and 148 were reviewed.

Discussion

Adolescents comprise a substantial portion of the population in many sub-Saharan African countries. They are at particular risk of HIV and may experience worse outcomes. Although demonstrated to have unique challenges, there is a dearth of comprehensive health services for adolescents, especially for those with HIV in sub-Saharan Africa. ART adherence is poorer among older adolescents than other age groups, and psychosocial, socio-economic, individual, and treatment-related factors influence adherence behaviour among adolescents in this region. With the exception of a few examples based on affective, cognitive, and behavioural strategies, most adherence interventions have been targeted at adults with HIV.

Conclusions

Although higher levels of ART adherence have been reported in sub-Saharan Africa than in other well-resourced settings, adolescents in the region may have poorer adherence patterns. There is substantial need for interventions to improve adherence in this unique population.

HIV in Harare: the role and relevance of social stigma

HIV is a significant social, political and economic problem in Zimbabwe. However, few researchers have explored peoples' experiences of living with HIV in that country. Drawing on 60 qualitative interviews conducted with Zimbabweans living in Harare in 2010, this paper focuses on how people from four different urban communities cope with HIV-related social stigma. To provide theoretical context to this issue, we utilised the ideas of Erving Goffman for exploring the individual experience of stigma and the concept of structural violence to understand stigma as a social phenomenon. This paper considers the relevance and role of stigma in the context of a country undergoing significant social, political and economic crisis. We investigated the strategies adopted by the Zimbabwean state and the influence of traditional and religious interpretations to appreciate the historical roots of HIV-related stigma. We took into account the ways in which the articulation of HIV with gender has caused women to experience stigma differently than men, and more intensely, and how grassroots activism and biomedical technologies have transformed the experience of stigma.

Making sense of HIV stigma: Representations in young Africans' HIV-related narratives

In addition to undermining the quality of life of those infected and affected by HIV, HIV-related stigma impedes access to prevention and treatment services, thereby threatening to erode the promise of recent advances in these areas. This paper provides insights into the socio-contextual and sense-making processes that inform HIV stigma through an innovative form of empirical data: creative fictional narratives written by young Africans (aged 10-24) for an HIV-themed scriptwriting competition. From a sample of 586 narratives from six sub-Saharan countries, we selected for illustrative purposes three on account of the complexity of their representation of HIV stigma. We conducted a close reading of each, using stigma theory as a lens. Through their explicit accounts of stigmatising attitudes and behaviours of characters and through implicit contradictions, tensions and ambivalence in their messaging, the narratives provide insights into the symbolic and social processes that create and sustain HIV stigma. Our analysis illuminates the authors' struggles to navigate the cultural resources available to them in their efforts to make sense of HIV, gender and sexuality. It highlights some limitations of current communication efforts and the potential for narrative-based communication approaches to engage with representations that devalue women and people living with HIV.

Obstacles to HIV prevention, treatment and care in selected public universities in South Africa

South Africa, like the rest of Southern Africa, is ravaged by AIDS. Higher education in South Africa has a significant role to play in the fight against the spread of HIV and AIDS. This article reports the factors contributing to the spread of HIV and AIDS in three selected public universities in South Africa. To achieve the stated aim, the study answered the following research question: What are the factors contributing to the spread of HIV and AIDS in South African public universities? The problem in this study stems from South Africa's HIV and AIDS infection rate, one of the highest in the world, especially in KwaZulu-Natal. A qualitative approach was adopted by conducting focus group interviews with the students. The data were analysed using axial coding and open coding, where dominant themes from the discussions were identified and discussed in detail. The findings show that barriers to HIV and AIDS prevention, care and treatment exist in the tertiary institutions under study. Social and economic interventions are needed to stem the spread of HIV and AIDS at tertiary institutions. A range of recommendations for halting the spread of HIV and AIDS in these institutions is provided.

HIV Treatment Scale-Up and HIV-Related Stigma in Sub-Saharan Africa: A Longitudinal Cross-Country Analysis

OBJECTIVES

We estimated the association between antiretroviral therapy (ART) uptake and HIV-related stigma at the population level in sub-Saharan Africa.

METHODS

We examined trends in HIV-related stigma and ART coverage in sub-Saharan Africa during 2003 to 2013 using longitudinal, population-based data on ART coverage from the Joint United Nations Program on HIV/AIDS and on HIV-related stigma from the Demographic and Health Surveys and AIDS Indicator Surveys. We fitted 2 linear regression models with country fixed effects, with the percentage of men or women reporting HIV-related stigma as the dependent variable and the percentage of people living with HIV on ART as the explanatory variable.

RESULTS

Eighteen countries in sub-Saharan Africa were included in our analysis. For each 1% increase in ART coverage, we observed a statistically significant decrease in the percentage of women (b = -0.226; P = .007; 95% confidence interval [CI] = -0.383, -0.070) and men (b = -0.281; P = .009; 95% CI = -0.480, -0.082) in the general population reporting HIV-related stigma.

CONCLUSIONS

An important benefit of ART scale-up may be the diminution of HIV-related stigma in the general population.

How disclosure and antiretroviral therapy help HIV-infected adolescents in sub-Saharan Africa cope with stigma

HIV-related stigma has a major impact on the health and psychosocial wellbeing of HIV-infected children and youths. While there is some debate about the extent to which improved access to antiretroviral therapy (ART) contributes to a reduction in HIV stigma, we know little about how adolescents who know their HIV status and who are enrolled in ART experience and cope with stigma. The aim of the research was to understand and identify the pathways between HIV-status disclosure, ART, and children's psychosocial wellbeing, including from the perspective of adolescents themselves. Two qualitative studies were carried out, in Botswana and Tanzania, in 2011: 16 adolescents and three healthcare workers were enrolled in Botswana, and 12 adolescents and two healthcare workers were enrolled in Tanzania. The data were collected through individual and group interviews as well as participant observation. The recorded interviews were transcribed and analysed using thematic network analysis. The findings indicate that HIV-status disclosure enabled adolescents to engage effectively with their ART treatment and support groups, which in turn provided them with a sense of confidence and control over their lives. Although the adolescents in the two studies were still experiencing stigma from peers and community members, most did not internalise these experiences in a negative way, but retained hope for the future and felt pity for those untested and uninformed of their own HIV status. We conclude that disclosure and good HIV-related services provide an important platform for HIV-infected adolescents to resist and cope with HIV stigma.

Perceptions of HIV, AIDS and tuberculosis among patients on antiretroviral therapy in Bulawayo, Zimbabwe: implications for the provision of HIV and TB care services

The objectives of the research were to explore perceptions of HIV, AIDS and tuberculosis (TB) among individuals enrolled in antiretroviral therapy (ART) at two municipal clinics in Bulawayo, Zimbabwe, and to assess the implications of these perceptions on the provision of HIV and TB care services. Data were collected using the freelist technique to elicit the elements of a cultural domain as well as open-ended interviews with ART clients, conducted during June and July 2009. Participants were recruited through non-probability convenience sampling. The freelist data were analysed using multidimensional scaling and hierarchical clustering, and the interview data were analysed using the grounded theory method. The results suggest that: 1) the participants had substantial knowledge about HIV, AIDS and TB; 2) the participants' perceptions of HIV, AIDS and TB constituted three distinct, though overlapping, cultural domains; 3) because of the availability of ART and TB treatment, a diagnosis of HIV infection or TB alone was generally perceived with hope that one would be able to live a normal life, while AIDS illness or TB/HIV coinfection were associated with notions of death and despair; and, 4) such perceptions may negatively impact the uptake of testing for HIV and TB, and thereby contribute to delayed start of the respective treatment. Health messages should build on these meanings which have the potential to either enhance or compromise available health programmes and their use by people living with HIV or TB.

Implementation and operational research: evaluating outcomes of patients lost to follow-up in a large comprehensive care treatment program in western Kenya

BACKGROUND

Academic Model Providing Access To Healthcare (AMPATH) program provides comprehensive HIV care and treatment services. Approximately, 30% of patients have become lost to follow-up (LTFU). We sought to actively trace and identify outcomes for a sample of these patients.

METHODS

LTFU was defined as missing a scheduled visit by ≥3 months. A randomly selected sample of 17% of patients identified as LTFU between January 2009 and June 2011 was generated, with sample stratification on age, antiretroviral therapy (ART) status at last visit, and facility. Chart reviews were conducted followed by active tracing. Tracing was completed by trained HIV-positive outreach workers July 2011 to February 2012. Outcomes were compared between adults and children and by ART status.

RESULTS

Of 14,811 LTFU patients, 2540 were randomly selected for tracing (2179 adults, 1071 on ART). The chart reviews indicated that 326 (12.8%) patients were not actually LTFU. Outcomes for 71% of sampled patients were determined including 85% of those physically traced. Of those with known outcomes, 21% had died, whereas 29% had disengaged from care for various reasons. The remaining patients had moved away (n = 458, 25%) or were still receiving HIV care (n = 443 total, 25%).

CONCLUSIONS

Our findings demonstrate the feasibility of a large-scale sampling-based approach. A significant proportion of patients were found not to be LTFU, and further, high numbers of patients who were LTFU could not be located. Over a quarter of patients disengaged from care for various reasons including access challenges and familial influences.

What am I 'living' with? Growing up with HIV in Uganda and Zimbabwe

As paediatric HIV treatment has become increasingly available across the world, the global perinatally infected cohort is ageing. However, we know surprisingly little about what it is like to grow up with HIV in resource-stretched settings. We draw on findings from a prospective, qualitative study with HIV-positive children, their carers and healthcare workers from four clinics in Uganda and Zimbabwe to examine children's experiences of living with HIV on treatment. We consider how the HIV experience is made in a symbiotic relationship between children, carers and healthcare workers and shaped by broader discourses. Despite the radical development in prognosis for children, their experience of HIV is largely constructed in relation to a language of 'sickness' through the promotion of medicalised talk and the recounting of past illness stories. This narrow narrative framework both reflects and reproduces core dimensions of the lived experience of growing up with HIV, which emphasises an absence of resilient healthiness in the face of ongoing vulnerability and risk. The challenges that children encounter in articulating alternative narratives that prioritise the relative buoyancy of their health is indicative of the broader uncertainty that exists around the future for these children at this point in the epidemic.

Persistent HIV-related stigma in rural Uganda during a period of increasing HIV incidence despite treatment expansion

OBJECTIVE

Programme implementers have argued that the increasing availability of antiretroviral therapy (ART) will reduce the stigma of HIV. We analyzed data from Uganda to assess how HIV-related stigma has changed during a period of ART expansion.

DESIGN

Serial cross-sectional surveys.

METHODS

We analyzed data from the Uganda AIDS Rural Treatment Outcomes study during 2007-2012 to estimate trends in internalized stigma among people living with HIV (PLHIV) at the time of treatment initiation. We analyzed data from the Uganda Demographic and Health Surveys from 2006 to 2011 to estimate trends in stigmatizing attitudes and anticipated stigma in the general population. We fitted regression models adjusted for sociodemographic characteristics, with year of data collection as the primary explanatory variable.

RESULTS

We estimated an upward trend in internalized stigma among PLHIV presenting for treatment initiation [adjusted b = 0.18; 95% confidence interval (CI), 0.06-0.30]. In the general population, the odds of reporting anticipated stigma were greater in 2011 compared with 2006 [adjusted odds ratio (OR) = 1.80; 95% CI, 1.51-2.13], despite an apparent decline in stigmatizing attitudes (adjusted OR = 0.62; 95% CI, 0.52-0.74).

CONCLUSION

Internalized stigma has increased over time among PLHIV in the setting of worsening anticipated stigma in the general population. Further study is needed to better understand the reasons for increasing HIV-related stigma in Uganda and its impact on HIV prevention efforts.

Linkage to HIV care, postpartum depression, and HIV-related stigma in newly diagnosed pregnant women living with HIV in Kenya: a longitudinal observational study

Background

While studies have suggested that depression and HIV-related stigma may impede access to care, a growing body of literature also suggests that access to HIV care itself may help to decrease internalized HIV-related stigma and symptoms of depression in the general population of persons living with HIV. However, this has not been investigated in postpartum women living with HIV. Furthermore, linkage to care itself may have additional impacts on postpartum depression beyond the effects of antiretroviral therapy. We examined associations between linkage to HIV care, postpartum depression, and internalized stigma in a population with a high risk of depression: newly diagnosed HIV-positive pregnant women.

Methods

In this prospective observational study, data were obtained from 135 HIV-positive women from eight antenatal clinics in the rural Nyanza Province of Kenya at their first antenatal visit (prior to testing HIV-positive for the first time) and subsequently at 6 weeks after giving birth.

Results

At 6 weeks postpartum, women who had not linked to HIV care after testing positive at their first antenatal visit had higher levels of depression and internalized stigma, compared to women who had linked to care. Internalized stigma mediated the effect of linkage to care on depression. Furthermore, participants who had both linked to HIV care and initiated antiretroviral therapy reported the lowest levels of depressive symptoms.

Conclusions

These results provide further support for current efforts to ensure that women who are newly diagnosed with HIV during pregnancy become linked to HIV care as early as possible, with important benefits for both physical and mental health.

HIV in (and out of) the clinic: biomedicine, traditional medicine and spiritual healing in Harare

Contemporary lived experiences of the human immunodeficiency virus (HIV) are shaped by clinical and cultural encounters with illness. In sub-Saharan countries such as Zimbabwe, HIV is treated in very different ways in various therapeutic contexts including by biomedical experts, traditional medicine and faith healers. The co-existence of such expertise raises important questions around the potencies and limits of medicalisation and alternative healing practices in promoting HIV recovery. First, in this study, drawing on in-depth qualitative interviews with 60 people from poor urban areas in Harare, we explore the experiences of people living with and affected by HIV. Specifically, we sought to document, interrogate and reflect on their perceptions and experiences of biomedicine in relation to traditional medicine and spiritual healing. Their accounts indicate that traditional medicine and spiritual beliefs continue to significantly influence the way in which HIV is understood, and the forms of help and care people seek. Second, we observe the dramatic and overwhelmingly beneficial impact of Antiretroviral Therapy and conclude through Zimbabwean's own stories that limitations around delivery and wider structural inequalities impede its potential. Lastly, we explore some practical implications of the biomedical clinic (and alternative healing practices) being understood as sites of ideological and expert contestation. This paper aimed to add to our knowledge of the relationships between traditional medicine and spiritual healing in connection with biomedicine and how this may influence HIV treatment and prevention.

From patient to person: the need for an 'HIV trajectories' perspective in the delivery of prevention of mother-to-child-transmission services

Accelerated efforts to end vertical HIV transmission have resulted in a 52% decrease in new infections among children since 2001. However, current approaches to prevent mother-to-child-transmission (PMTCT) assume a linearity and universality. These insufficiently guide clinicians and programmes toward interventions that comprehensively address the varying and changing needs of clients. This results in high levels of loss-to-follow-up at each step of the PMTCT cascade. Current PMTCT approaches must be adapted to respond to the different and complex realities of women, children and families affected by HIV. Drawing on the concept of an 'HIV trajectories,' we screened peer-reviewed literature for promising PMTCT approaches and selected 13 articles for qualitative review when the described intervention involved more than a biomedical approach to PMTCT and mother-child HIV treatment and care. Our qualitative analysis revealed that interventions which integrated elements of the 'HIV trajectories' perspective and built on people living with HIV support/network, community health worker, primary healthcare and early childhood development platforms were successful because they recognized that HIV is an illness, experienced, moderated and managed by numerous factors beyond biomedical interventions alone.On the basis of this review, we call for the adoption of an 'HIV trajectories' perspective that can help assess the comprehensiveness of care provided to women, children and families affected by HIV and can inform the planning and delivery of HIV and related services so that they more adequately respond to the varying needs of clients on different 'HIV trajectories'.

Internalized stigma, social distance, and disclosure of HIV seropositivity in rural Uganda

BACKGROUND

HIV is highly stigmatized, compromising both treatment and prevention in resource-limited settings.

PURPOSE

We sought to study the relationship between internalized HIV-related stigma and serostatus disclosure and to determine the extent to which this association varies with the degree of social distance.

METHODS

We fit multivariable Poisson regression models, with cluster-correlated robust estimates of variance, to data from 259 persons with HIV enrolled in an ongoing cohort study in rural Uganda.

RESULTS

Persons with more internalized stigma were less likely to disclose their seropositivity. The magnitude of association increased with social distance such that the largest association was observed for public disclosures and the smallest association was observed for disclosures to sexual partners.

CONCLUSIONS

Among persons with HIV in rural Uganda, internalized stigma was negatively associated with serostatus disclosure. The inhibiting effect of stigma was greatest for the most socially distant ties.

Reversal of the Kynurenine pathway of tryptophan catabolism may improve depression in ART-treated HIV-infected Ugandans

BACKGROUND

Major depressive disorder is highly prevalent among HIV-infected persons, and depression symptom severity improves during the course of HIV antiretroviral therapy (ART). The potential biologic pathways explaining these phenomena remain unclear. We investigated the extent to which ART-mediated suppression of the kynurenine pathway of tryptophan catabolism (via indoleamine 2,3-dioxygenase-1 and potentially other sources) may correlate with improvements in depression symptom severity in this setting.

METHOD

We used the first year of data from the Uganda AIDS Rural Treatment Outcomes Study, a prospective cohort of 504 HIV-infected individuals initiating their first ART regimen in rural Uganda. We fitted random-effects regression models to estimate the associations between plasma tryptophan, plasma kynurenine, dietary diversity, and self-reported depression symptom severity.

RESULTS

Greater depressive symptoms were associated with both lower plasma tryptophan and higher plasma kynurenine/tryptophan (KT) ratio over 12-month follow-up. In multivariable-adjusted models, declines in KT ratio and increases in plasma tryptophan levels partially explained ART-mediated improvements in depressive symptom severity. The association between KT ratio and depression symptom severity was stronger among persons with protein-deficient diets than among those with protein-rich diets.

CONCLUSIONS

Indoleamine 2,3-dioxygenase-1-mediated tryptophan catabolism may contribute to depression symptom severity among HIV-infected individuals, particularly among those with poor dietary protein intake. ART-mediated improvements in depressive symptom severity may also be at least partially mediated by immunologic mechanisms. Interventions to reduce immune activation, and dietary protein supplementation, may be promising strategies to further reduce depression in this setting.

Resisting and challenging stigma in Uganda: the role of support groups of people living with HIV

INTRODUCTION

Global scale up of antiretroviral therapy is changing the context of HIV-related stigma. However, stigma remains an ongoing concern in many countries. Groups of people living with HIV can contribute to the reduction of stigma. However, the pathways through which they do so are not well understood.

METHODS

This paper utilizes data from a qualitative study exploring the impact of networked groups of people living with HIV in Jinja and Mbale districts of Uganda. Participants were people living with HIV (n=40), members of their households (n=10) and their health service providers (n=15). Data were collected via interviews and focus group discussions in 2010, and analyzed inductively to extract key themes related to the approaches and outcomes of the groups' anti-stigma activities.

RESULTS

Study participants reported that HIV stigma in their communities had declined as a result of the collective activities of groups of people living with HIV. However, they believed that stigma remained an ongoing challenge. Gender, family relationships, social and economic factors emerged as important drivers of stigma. Challenging stigma collectively transcended individual experiences and united people living with HIV in a process of social renegotiation to achieve change. Groups of people living with HIV provided peer support and improved the confidence of their members, which ultimately reduced self-stigma and improved their ability to deal with external stigma when it was encountered.

CONCLUSIONS

Antiretroviral therapy and group-based approaches in the delivery of HIV services are opening up new avenues for the collective participation of people living with HIV to challenge HIV stigma and act as agents of social change. Interventions for reducing HIV stigma should be expanded beyond those that aim to increase the resilience and coping mechanisms of individuals, to those that build the capacity of groups to collectively cope with and challenge HIV stigma. Such interventions should be gender sensitive and should respond to contextual social, economic and structural factors that drive stigma.